Nursing Elites

1. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets and has a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?

• A. Monitor the client's IV site for thrombophlebitis
• B. Administer flumazenil to the client
• C. Evaluate the client for further suicidal behavior
• D. Initiate seizure precautions for the client

Correct answer: B

Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Monitoring the IV site for thrombophlebitis (choice A) is important but not the next immediate action. Evaluating the client for further suicidal behavior (choice C) is important but not the priority at this moment. Initiating seizure precautions (choice D) is not the priority action in this scenario.

2. A nurse is planning care for a client who has pneumonia. Which of the following actions should the nurse take to promote airway clearance?

• A. Perform chest physiotherapy every 4 hours.
• B. Suction the client every 2 hours.
• C. Encourage the client to increase fluid intake.
• D. Administer oxygen via nasal cannula.

Correct answer: C

Rationale: Encouraging the client to increase fluid intake is essential in promoting airway clearance for a client with pneumonia. Increased fluid intake helps thin secretions, making it easier for the client to clear their airways. Chest physiotherapy (Choice A) is more focused on mobilizing secretions and may not be suitable for all clients with pneumonia. Suctioning (Choice B) is indicated for clients who have excessive secretions that they cannot manage effectively themselves. Administering oxygen via nasal cannula (Choice D) is important for clients with pneumonia to maintain adequate oxygenation, but it does not directly promote airway clearance.

3. A nurse is preparing to administer a dose of amoxicillin to a client who has an allergy to penicillin. Which of the following actions should the nurse take?

• A. Administer the medication as prescribed.
• B. Verify the client's allergy status before administering the medication.
• C. Ask the provider to prescribe a different antibiotic.
• D. Check the client's skin for any rashes before administering the medication.

Correct answer: C

Rationale: In this scenario, the nurse should ask the provider to prescribe a different antibiotic instead of administering amoxicillin to a client with a known penicillin allergy. Choice A is incorrect because administering amoxicillin to a client with a penicillin allergy can lead to an allergic reaction. Choice B is not the best option as simply verifying the client's allergy status does not address the potential harm of giving amoxicillin. Choice D is irrelevant as checking the client's skin for rashes does not address the issue of administering a potentially harmful medication. Therefore, the most appropriate action is to request a different antibiotic from the provider to ensure the safety of the client.

4. What is the most important assessment for a patient with suspected pneumonia?

• A. Monitor lung sounds
• B. Check oxygen saturation
• C. Assess for cough
• D. Assess for fever

Correct answer: A

Rationale: The most important assessment for a patient with suspected pneumonia is to monitor lung sounds. Lung sounds provide crucial information about the severity of pneumonia, such as crackles or decreased air entry. This assessment helps in evaluating the effectiveness of ventilation and oxygenation. While checking oxygen saturation is important, monitoring lung sounds gives more direct information about the lung involvement in pneumonia. Assessing for cough and fever are also relevant but do not provide as direct and critical information as monitoring lung sounds in the context of suspected pneumonia.

5. A nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infections is a nationally notifiable infectious disease that should be reported to the state health department?

• A. Chlamydia
• B. Human papillomavirus
• C. Candidiasis
• D. Herpes simplex virus

Correct answer: A

Rationale: Chlamydia is the correct answer. It is a sexually transmitted infection that is nationally notifiable, meaning healthcare providers are required to report cases to the state health department. This is crucial for disease surveillance, monitoring, and implementing public health interventions. Human papillomavirus, Candidiasis, and Herpes simplex virus are not nationally notifiable infectious diseases and do not require mandatory reporting to the state health department.

Similar Questions